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How to approach NBME/USMLE questions

There is more to the USMLE than the requisite volume of knowledge, and you can take the test efficiently by acknowledging outright the things your subconscious probably already knows. This is a somewhat randomly chosen question from the official 2013 USMLE Step 1 information booklet:

A previously healthy 48-year-old man comes to the physician because of fever and cough for 2 days. He attended a convention 10 days ago, and two of his friends who stayed in the same hotel have similar symptoms. His temperature is 38.3°C (101°F), pulse is 76/min, respirations are 20/min, and blood pressure is 130/70 mmHg. Crackles are heard over the right lung base. A chest x-ray shows a patchy infiltrate in the right lower lobe. A Gram stain of sputum shows segmented neutrophils and small gram-negative rods that stain poorly. A sputum culture grows opal-like colonies on yeast extract. Which of the following is the most likely causal organism?

Once you’ve done enough Step questions, you will already know the most likely answer at the word “convention” (it’s C). Not every question can come as a knee-jerk reaction, but one key to Step preparation is not just overall knowledge but rather pattern-recognition and memorization.

What separates the massive scores from the excellent scores boils down to intrinsic genius, test-taking voodoo, and tons of studying. The first you can’t change; the third you have to do (and should do efficiently). The second you need to be clever about (and doing questions is key). You can lay a strong foundation by making questions like the one above comically easy. Knowing the key phrases and patterns can allow you to literally “feel” the right answer even without having conscious knowledge. If you can get in the head of the question writer and know the tip-offs, you can often make a reasonable guess even if you don’t actually know the “basic science” details the question is supposedly trying to test.

Rid Yourself of Your MCAT Bias

Start by acknowledging that the USMLE is different from the MCAT. Knowledge during the MCAT is a foundation that allows you to reason through a question to arrive at an answer. Knowledge in the USMLE is frequently the answer itself. There is minimal critical thinking involved. The slight exception is physiology, which requires knowing more complex relationships (this goes up; this and that go down; the other thing stays the same), which can also be memorized (though it is more cumbersome to memorize than to intuit). Most of the test, however, is the straightforward application of memorization dressed in the clothing of painfully verbose question-writing and enough length to exhaust your sympathetic reserves.

MCAT and USMLE scores do correlate (of course they do). Know, however, that there are people who perform very poorly on the MCAT that end up with massive Step scores. This is because you can brute force your way to a solid score with questions, while it’s very difficult to improve your verbal subscore on the MCAT.

Use the Force

The “test-taking” skill itself comes into play only in knowing when they’re trying to play you for a fool. Inexperienced test-takers will second-guess themselves out of the correct answer or hinge their guesses on irrelevant “clues.” Good test-takers get in the head of the question writer. Another official example:

A 24-year-old primigravid woman at 28 weeks’ gestation has had nagging headaches, a puffy looking face, and swollen legs for the past week. Her blood pressure is 180/95 mm Hg; it was within normal limits earlier in the pregnancy. Urinalysis shows a protein concentration of 0.6 g/dL. Which of the following is the most likely diagnosis?

The answer is E. This is classic preeclampsia, and the question goes out of its way to list an almost comical number of criteria. That said, it’s a question about a pregnant patient with a seemingly pregnancy-related problem. Only two of the five choices is specific to pregnancy. Question writers very rarely include totally extraneous details, so you should be looking for a pregnancy problem first and foremost before believing the voice on your shoulder telling you that they’re trying to mislead you. So, ask yourself: if you didn’t know anything at all about the actual criteria, which answer would you guess? You should be guessing E (C requires a seizure).

USMLE questions are “single best answer.” That doesn’t mean the other answers are 100% wrong or that they aren’t even reasonable. They’re just not the best. People find elements in the stem that support other choices, and these force them to reconsider their gut (and usually correct) feeling. Your feelings (except for that miasma of anxiety) matter, so don’t ignore them.

In the above question, edema supports CHF and nephrotic syndrome. Proteinuria supports GN, and if it were of a larger amount, nephrotic syndrome. These answer choices having true elements doesn’t take away from the fact that preeclampsia explains all of them.

But even if you don’t know anything, your goal when guessing is to narrow down answer choices. Think about the body systems involved, the time courses, acquired versus congenital, viral vs bacterial, drug reactions, any answer choices you do recognize that you know can’t be it. Cross stuff out.

Which of the following is the most likely diagnosis? (A) Aldosterone deficiency (B) Anxiety reaction with hyperventilation (C) Diabetic ketoacidosis (D) Ingestion of anabolic steroids (E) Surreptitious use of diuretics

“Female athlete” is a code word for “eating disorder” (the answer is E). If the question mentioned a boxer, wrestler, or other sport with weigh-ins, ditto. Board questions reflect an extremely judgmental worldview with heavy-handed generalizations about race, sex, and a wide variety of stereotypes. African-American females in their 30-40s have sarcoidosis. If a woman takes oral contraceptive pills, the question is nearly always implying that she doesn’t use barrier protection and has contracted an STD. People who have recently immigrated from another country with cough have tuberculosis. If it’s a child who has recently immigrated, then they have a vaccine-preventable illness.

Often, in order to allow you to reasonably pick an obscure or rare illness with a set of non-specific symptoms, these giveaways make sense. Sometimes they just make the question easier. Other times, it’s a second-order question and simply knowing the diagnosis isn’t enough anyway. But always look for a question’s internal clues to help you guess, give you the answer, or boost your confidence. You can’t learn every fact, and sometimes you don’t have to. When picking facts to learn from a long list of tidbits, pick the ones that help distinguish a diagnosis from other likely/related answer choices.

Dealing with irritating clinical science questions

Which of the following is the most appropriate next step in management? Which of the following is the most appropriate next step in diagnosis?

These question styles can make you question yourself and frustrate you in times when you otherwise could have sworn you knew the answer. Here are a couple of takeaways using examples from the official Step 2 CK information booklet:

In emergencies/unstable patients, your “go to” answer is whichever one prevents death or most stabilizes the patient. So, in the trauma setting, follow your ABCs (where “C” essentially always means fluid resuscitation). For example, if tension pneumothorax is a possibility, then needle decompression must be performed without delay. Always follow an algorithmic approach with the goal of stabilization and prevention of avoidable complications. The “definitive” management is almost always available as an answer choice and usually must be avoided for this style of question. In real life, many things happen simultaneously, but while studying, always think about which thing is the most crucial to perform.

A 22-year-old man is brought to the emergency department 30 minutes after he sustained a gunshot wound to the abdomen. His pulse is 120/min, respirations are 28/min, and blood pressure is 70/40 mm Hg. Breath sounds are normal on the right and decreased on the left. Abdominal examination shows an entrance wound in the left upper quadrant at the midclavicular line below the left costal margin. There is an exit wound laterally in the left axillary line at the 4th rib. Intravenous fluid resuscitation is begun. Which of the following is the most appropriate next step in management?

This gentleman has a GSW to the abdomen extending to the thorax with ipsilateral respiratory compromise from a hemothorax. You may remember from your studying that all GSWs to the abdomen will go for exploratory laparotomy. But first things first, he has earned himself a chest tube (choice E). After all, B comes before C in ABC. Now, if he were stable after the tube is in, he might get a CT before going to the OR (B). He will certainly be intubated for surgery (C). But never forget your ABCs. Don’t get excited. Even if exploratory laparotomy or thoracotomy were answer choices, they would also be wrong.

When patients are stable, the “next best step/most appropriate test” is that which is most likely to make the diagnosis (always know the test of choice, especially for imaging studies) or rule out a less-likely but potentially life-threatening diagnosis. If the diagnosis is already made, treat the problem (there may be two or more treatments, but one is more important). Other tests may be reasonable and performed concurrently in real life, but there is typically one test that is geared towards the most likely diagnosis based on presentation. That’s the one you want. You should have some knee-jerk associations for complaints (e.g. LLQ pain and fever – diverticulitis – CT scan of the abdomen with contrast; RUQ pain and fever – cholecystitis – RUQ abdominal sonogram). When given a classic but non-acute disease presentation, always think about how to prevent catastrophic consequences.

42-year-old woman comes to the physician because of a 1-year history of vaginal bleeding for 2 to 5 days every 2 weeks. The flow varies from light to heavy with passage of clots. Menses previously occurred at regular 25- to 29-day intervals and lasted for 5 days with normal flow. She has no history of serious illness and takes no medications. She is sexually active with one male partner, and they use condoms inconsistently. Her mother died of colon cancer, and her maternal grandmother died of breast cancer. She is 163 cm (5 ft 4 in) tall and weighs 77 kg (170 lb); BMI is 29 kg/m2. Her temperature is 36.6°C (97.8°F), pulse is 90/min, respirations are 12/min, and blood pressure is 100/60 mm Hg. The uterus is normal sized. The ovaries cannot be palpated. The remainder of the examination shows no abnormalities. Test of the stool for occult blood is negative. Which of the following is the most appropriate next step in diagnosis?

Now, there is a rule about abnormal vaginal bleeding in women over 35, but let’s say you didn’t know that. Ask yourself, what would be the worst thing to cause non-acute bleeding? What would you want to rule out? Cancer. Could it be that she has amenorrhea and that a progesterone challenge test could answer our question? Absolutely. But we must rule out the life-threatening cause. The answer is E.

So—

Stabilize if necessary — ABCs, even for non-trauma patients

Diagnose if necessary — Test of choice to make the diagnosis or the test that will rule out a potentially life-threatening cause

Treat — If there are multiple appropriate options, which one is the most crucial?

Ultimately, most questions are fair. That said, every once in a while, the question is actually terrible. If after all is said and done, it makes no sense, don’t extrapolate too much from it for your general test-taking skills.

Managing Anxiety

There are always miserably hard questions on NBME Shelf and USMLE Step exams, and that’s okay. It’s not realistically possible to get them all right. The nature of the test is such that a ball of doubt will form deep in the core of your body, growing with each question you waver on. And, the test is designed to make you waver over that second answer choice which doesn’t feel right (but you can’t explain why it’s wrong). Allow yourself to approach the tests with an air of dispassion and nonchalance. Your nerves don’t help you. Your instincts do.

Stay awake. Stay focused. Use what they give you to make your life easier. When you don’t know an answer, try to narrow it down based on internal characteristics, guess, and move on. If you go back to change an answer, you must know why and have a good reason. Never change an answer arbitrarily because of feelings.

94 Comments

First, thanks for this site, I read it all the time. In your opinion, for step 2 ck.. how do you suggest to tackle these type of questions: -What is the most appropriate diagnostic test for this patient? -What is the next best step in management?

Thanks for the kind words. You’ve made special note of the most frustrating question style, which often presents an unrealistic scenario by forcing you to choose between multiple things that would happen simultaneously in the real life (with the correct choice often seeming somewhat arbitrary). Ultimately, there actually is a rhyme and reason. Part of the trick is doing lots of UW questions and making sure to memorize the examples (and think hard about trends within the style).

My thoughts:

[I’ve expanded on my answer to your question and moved my response to the body of this essay under the heading “Dealing with irritating clinical science questions.”]

Thank you so much for the tips. What to do when you are stuck between 2 answers and you know one of them is the right answer. You are running out of time and you have to pick one and move on! What is your suggestion in that situation. Thank you!

The fastest solution is to go with your gut instinct and run. Just pick the one that seems right first. It’s almost never a good idea to change your answer or talk yourself out of your original choice. Only if you know exactly why you’re changing your answer should you do so. Just doing so out of nervousness or because you’re not sure is a terrible idea.

When you’re down to two choices, try to see if one answer might feel more right. Often, you will like one answer better but won’t be able to “rule out” a second choice. This second choice sometimes seems like it could be correct. The USMLE uses a “single best answer” format. This means that other answers don’t all have to be wrong, just one of them stands out as better. You don’t technically have to know the right answer, you just have pick it.

Lastly, instinctively guessing the correct choice is another reason to do tons and tons of practice questions from a reputable source. You can develop your innate question sense by practicing and practicing. Using low-budget or alternative questions can be a bit dangerous, as some of these resources over-test minutia or try to trick you in ways that are not typical of the real USMLE.

Thanks for this perspective on the USMLE. I got a 35+ MCAT but did only average on Step 1. I’ve always preferred the critical thinking emphasized on the MCAT to the rote memorization and recall for Step and in my attempt to deduce the answer I overanalyze and frequently find myself choosing the 2nd best answer. It’s not that easy to “rid yourself of the mcat bias” as you say, though that’s prob right direction.

I think it’s way harder to get 35 on MCAT than a >240 on Step 1. I have average MCAT scores and a 249 on Step 1. A buddy of mine who was in premed classes with me, is super smart and hard working, and scored the same as me on every undergrad and med school test we had together scored shittily on his step exam. It boggles my mind to think that he’ll be looked at disapprovingly by programs because of that score–when in truth he’s a top notch student, better than I am in fact.

Don’t forget: little is known about the NBME scoring algorithm. The test was designed to be pass/fail only, and the scores were never supposed to mean anything super significant. Especially the three digit scores.

Cheers, and nice work on that MCAT. If I was the program director, I’d want you based on that (more than a 240 on step 1).

Dear Dr. White, Thank you so much for the wonderful advice for a lifetime here.

May I ask you for an advice please? Here’s my situation in my preparation for Step 1. My strategy was to collect high yield materials from other sources and put onto FA(First Aid), and then study and memorize FA. Then, within a week towards the REAL Exam, I would do 400-500 UW Questions, and hopefully I will be set. Now that my Exam is in 5 days and I have NOT done any UW questions because I feel like I am not ready to do questions. It sounds stupid, very stupid, but it is true. If I don’t take the Exam, I will have to re-register and pay another whole fee of $800+ because I already have extended once.

What should I do? Should I take it or just don’t show up at the test center, and re-register and do UW Questions for the next 2-3 months and then sit for the Exam? My family wanted me to take it anyway, but I don’t want to fail, but I don’t have the confidence.

My feeling is, whether or not your preparation was optimal, the only way to get an idea of what will happen on test day is take some practice tests. Take the UW practice exam or a couple of NBME samples. If you’re comfortably passing the practice exams, then you’re likely to do the same on the real thing. Then you have to decide if the range of your performance is something you’re okay with. Rescheduling isn’t necessarily the end of world, but you’ll feel much better doing it if you know it’s necessary and not just doing it out of (potentially unfounded) fear.

Hi I found your article really helpul.I am realy worried right now COz my eligibility period will end in November but I have to leave for my home country to see my parents by early November. I took nbme 11 in september and scored 213 and after revising first aid again I took nbme 13 today and score 198 that I such a bummer coz i was planning to take my exam in next 2 weeks. I really don’t know what to do. I have done kaplan books twice with lectures(except pharma and anatomy) First aid almost 4 times Goljan with audios once Uworld once going over explanations again I really don’t know what I can do now to improve my situation I can change the testing region or take it by 2nd of November here… Any advice will be really really appreciated :)

It’s hard to say what will help you most in the home stretch. In part, it would depend on where your weaknesses are and the main reasons behind why you get questions wrong. At this point, it’s often a lack of question-taking familiarity more than overt knowledge, in which case spending more time with UW would be most helpful.

Dear Ben, I found your link on google searching for other things, it’s really nice of you to share your precious time with us. I would like you to ask you some advice about improving my performance because my real problem is anxiety and low self confidence. I did UW the first time I got 70% and the 2nd time 84% I feel that I am not ready!! And the big day is coming soon in the next 4 weeks…I don´t know what to do… I took the NMBE 1 & 2 offline (does not in 4hours) I got 82 and 83% respectively, I changed a lot of good answer for no reason, that´s the mean problem. I did the same for step 1 and I almost failed I got 209..could you please give me some advice? Thank you.

1) Those percentages are very good, plenty to net you a great score. Don’t psych yourself out, you’re ready knowledge-wise.

2) Make yourself a rule: never change your answer. If you’re hitting a high percentage on UW, then your automatic answers are good. Most people hurt themselves more often than not when switching in general. My normal advice is to only switch when you are absolutely sure the other answer is correct and know you made a clear mistake in your original choice. But if the ability to switch is what causes you anxiety, just never switch.

1) There is a tumor involved in leydig cell tumors. 2) Aromatase deficiency is a (very rare) congenital abnormality. Leydig cell tumors are acquired and thus have symptoms later in life, most frequently during young adulthood. 3) Aromatase deficiency will result in low estogrogen and high androgens (+/- high testosterone) because aromatase normally converts androgens to estrogen. Leydig tumors can (but do not always) produce testosterone, but they do not lower estrogen levels.

Never forget that the real thing can really feel terrible. It’s long and you never get any positive reinforcement. The questions you had to guess on will weigh heavily in your mind. This is all test psychology. How it feels doesn’t actually matter; chances are you are doing exactly as well as you normally do, and that’s what you need to tell yourself as you go through the day to make that true.

Thank you for your really informative article. Please what will you advise as focus of study for someone who scored 220(83 incorrect)on NBME 7 ,most incorrect from General principles of health and disease and who has to write the test in 2months

The category “General Principles of Health and Disease” is a catch-all for the basics of many fields, including basic microbio, physiology, pharmacokinetics and pharmacodynamics, tissue response to injury (basic pathology), cell and microbiology / biochem, etc. This is to say it’s a broad foundational catch-all, and there’s no specific advice other than the general advice (for which 2 months is plenty): review everything, focus on questions.

hi! thank you for this! very helpful!! i’m currently a 2nd year med student in the Philippines. would you mind giving me advice on how to schedule my studies? i can’t study during school days but i’m on vacation for 5 weeks before the 2nd semester starts. i’m planning to do some reading now and tons of questions during the summer break before the exams. thank you!!!

3 weeks is a long time, and don’t read too much into varying performance on a single practice exam. Focus on questions, take time to savor the explanations.

In particular, each question contains several possible additional questions in the form of the alternative answer choices. UW explains what in the question stem makes the best answer the correct one, but the explanations also teach you what factors would lead you to the alternatives. This is one way how doing a limited number of questions can prepare you to answer questions you’ve never seen. Learn to unlayer the stem; each line is in there for a reason.

Hi Ben, I ran into a practice question from a qbank that is very similar to the trauma case? That particular question has similar presentation except patient’s vital sign is stable. And among the familiar choices, CXR is selected as right answer because obtaining a radiologic diagnosis of the exact nature and extent of the problem (the patient is fully awake and alert, no distended neck veins), and chest tube thoracostomy is wrong because should not be inserted blindly without yet knowing what is going on. The patient may very well need a tube at the pleural base if the x-ray film shows a hemothorax, but the physician might prefer to put it at the top if all there is in the pleural space is air. What is your opinion on the answer of this particular question?

It’s all about ABCs. If the patient’s airway is secure and he is breathing fine (i.e. he’s talking to you and his sats are okay), then A and B are taken care of. If his pulse and BP are WNL, then C is also fine. That leaves you with a stable patient that you need to work up!

In that situation a CXR gives you a gross analysis of his injuries (pneumothorax, hemothorax) which will guide the immediate management. If nothing obvious is going on or the findings don’t requirement an emergent chest tube, then the following step will be CT. GSWs to the chest, unlike the abdomen, don’t go straight to the OR.

Colposcopy is typically used to work-up abnormal paper smear results for cervical cancer or to further evaluate cervical abnormalities seen on a speculum. Not as a first-line test for bleeding. The question stem is unclear if a speculum exam was included in the physicial exam. If it was, then it was normal and no colposcopy would be indicated in the abscence of abnormal pap results. If it wasn’t, then that would be performed prior.

Additionally, the story here is more indicative of possible endometrial cancer vs dysfunctional uterine bleeding: cervical cancer typically does not cause menometrorrhagia as often as uterine cancer, in part because there is no uterus to collect the blood. So the bleeding is more commonly contact bleeding related to friable tissue after sexual activity, exams, etc. Lastly, her body habitus puts her at increased risk of endometrial cancer.

Take home point: if there is a DUB in a woman over 35, an EMB should be performed.

Hello Ben, thank you for being so helpful I got my score today, it´s not as good as I was wanting but acceptable. Score 232. I would like to apply for pediatrics and I got a bad score on step 1, (209). Do you think that I’ll still have great opportunities to get it? I´ll be graduated in May as family practice in Spain. Thank you once more.

The improvement is solid. Your Step 1 would be fine for a US grad but on the low side coming from elsewhere. The process of getting a residency spot is multifactorial, so it’s tough to say, but peds generally doesn’t employ minimum score cutoffs. Apply broadly, and don’t overlook community programs as well as the bigger non-flagship academic programs.

Hey Ben! Iv’e been reading your blog posts for sometime. I can’t seem to pass any NBME exams at all. I’ve had a few set backs, and took a year off from studying. But After that, I have been consistent with UW, FA, and Pathoma. When I go over the incorrect questions It disheartens me because most of the time I know the answer. I’ve noticed a pattern of it mostly linked to poor recall, and horrible test anxiety. I’m really lost and would appreciate any advice you have to offer. Thanks!

I remember that when I’d get questions wrong on UW, a lot of the time I would say, “oh wait, doesn’t count, I knew that one.” But the fact is that there is more than one way to get a question wrong. Most people think of really being “wrong” when they’re totally clueless, but that makes up a minority of cases. Most times you will actually know the fact being tested even when you get it wrong. Part of doing questions is continuing to pair up facts with answers, and it takes time.

One of the difficulties some of my former students had with studying through questions is that getting questions wrong can be demoralizing. To me, the bottom line is that when you’re studying with UW or any qbank, your goal isn’t to get questions right; your goal is to learn. There’s almost as much to learn from the questions you answer correctly as the ones you get wrong.

Ultimately, this process of demoralization and self-doubt feeds into your anxiety. This is a hard cycle to break. One thing I believe is that the more you care, the worse you do. If each time you’re not sure about an answer shakes your overall conscience, it’s going to be a very long test. Derealization is a helpful skill, because dispassionate nonchalance is a better mindset than “this test determines my future.”

Hey Ben, I really love your advice and how you explain the questions and your thought process-really helps and I’ve seen my score improve once I started to look at questions the way you explained how to. I had a question though, I’m an IMG and my step 1 score is a 189. I know, horrible- I actually was surprised I passed. I took way too long to study and my scores started to drop and I took it when I was in the 220 range on NBMEs but the morning of the test I just had so much anxiety and blanked for a lot of it :-/ anyway, I’m studying for step 2 now, what do you think I would be able to apply for realistically? Thank you!

Improving your Step 2 will be very important. Being a US IMG would also help regardless. I’d primarily focus on community programs, family medicine or psychiatry. My impression is that most of the IMG-centric community internal medicine programs most often are taking good “paper” candidates, though they also seem to largely be made up of true FMGs. Honestly not sure where they’d come down preference wise between native-speaker IMG with weaker scores vs FMG, though I’d imagine it varies (and I’d hope your school has its own historical data to guide you as well).

Thanks for all the advice you post its really helpful. I took my step one and i failed. Im quite discouraged esp since i am an us img. But i know my problem was lack if confidence and not doing enough questions. I have a 9 to 10 week study period now. I will take your advice and focus on questions. do you think i bother doing another qbank as well or shld i focus on uworld. i dont know if you have any particular advice for people who repeat but im trying to work hard and aim high this time around.

You’re not alone. I think anxiety and not doing enough questions probably account for essentially all regret when it comes to Step 1. The easy answer is that UW alone is enough until it’s not. If you’ve essentially memorized the whole thing, gone through it at least 1.5x, then one might consider moving on to Kalpan or Rx. Do a few sections on tutor mode at a leisurely pace and extrapolate how long it’ll take you and go from there. If you get another qbank, I’d personally study/master UW and then use the second qbank to simulate the test experience. An alternative would be to buy a bunch of the NBME pratice exams, but that can be quite pricey.

Ultimately, when it comes to retaking anything: If the previous failure motivates you, then use it as fuel to get through the inevitable tough times that dedicated study brings to your physical and emotional well being. If your previous failure makes you doubt yourself, second-guess yourself, question whether you have what it takes—it doesn’t. Forget about it. Give yourself some slack and a clean slate. There’s a reason why you can take the exam again. Your life isn’t the sum total of one 8 hours stretch.

I have been reading all the comments on this site. I took Step 2 ck last month and failed it by 20points. to be honest I expected not passing it when I walked out of exam. question stems were very long and I found myself debating over answer choices as I felt I forgot the basic stuff from Step 1. I would answer the last 6-7 questions from every block in matter of 4 minutes. I was depressed even going through the last 2-3 blocks. Anyways after leaving 2 weeks of depression behind and finally deciding to do this again, I decided to go over Step 1 first aid again, and go over uworld questions in timed mode only + master of the board book, and I took a NBME yesterday which I got 209, still not passing based on 210 new passing policy. My question from you is, do you recommend doing anything else aside from what I mentioned? I have this fear in me now that it will be my second time taking the exam but I want to take it towards the end of august. I would appreciate any honest word you might have for me. Thank you in advance.

My thoughts on Step 2 CK are summarized here. When you go through UW again, you mean UW Step 2 right? While Step 2 builds on Step 1 in many ways, the relevant “Step 1” info you need for Step 2 CK is within the Step 2 materials. Dedicated Step 1 review overall is probably not the highest yield use of time. I personally wouldn’t cover to cover read FA Step 1 again, much of the minutia is now irrelevent (and would probably be demoralizing as well). Step 2 CK is a clinically focused exam.

When you look at your UW stats, do they demonstrate any trends, areas where you are stronger or weaker? If you have weak areas (e.g. ob/gyn), then dedicated review for a week as if you were taking a shelf may be helpful.

Since time management has been a problem, then questions are probably where you need to focus the bulk of your time. Timed mode is good, just make sure you really take your time with the explanations after. If you’re able to finish but not doing well on your question percentage, then tutor mode at first may paradoxically be helpful to give you a better chance to learn the material as you go through. Everyone debates answer choices, but you’ll need to practice gaining and maintaining momentum within a section and then over multiple sections.

Hi Ben, majority of my studying prep will be doing practice questions from different sources. (goal : 5000-10,000 questions before test exam) do you suggest when doing questions to annotate a study guide review with links of pattern answers? Also, did it help to master 2 step process thinking and 3 step process thinking while doing Q bank? for instance, (repost from studentdoctorforum.com member: “each test question is the same: they present a classic clinical scenario say for…i dunno…sickle cell anemia. you immediately recognize the kid has sickle cell. then the question will be basically what is the mechanism of the drug you use to prevent sickle crises with? so it’s a three step process…1) recognize sickle cell, 2) remember that you prevent sickle crises with hydroxyurea and 3) hydroxyurea increases fetal hemoglobin (this is the answer)”

I think the decision to annotate anything is deeply personal (whether within a question bank, in First Aid, or in some Word document, massive PowerPoint slideshow, or complex spreadsheet). Some people absolutely SWEAR by their FA annotations and attribute their success to it. While I don’t want to say I don’t buy it, that method is definitely not for me (and it’s time consuming). I think the patterns generally emerge organically over the course of the study process. I suppose if after 2000 questions, you’re still hitting the same roadblocks when it comes to questions about common high yield topics, it may be worth revisiting the question.

It is absolutely worth mastering the process of second and third order questions (though to be clear, first order questions are actually quite common and third order much less so [except in UW, where they are seemingly omnipresent]). If you can answer the third order, you can nearly always answer the easier versions. It’s a great way for them to test you mechanisms of action, drug side effects, etc (i.e. these are not random additional facts, they are largely predictable over time). Typically, common topics (e.g. sickle cell, as in your example) are more likely to appear as high order questions. Esoterica, say, a question about brucellosis, is more likely to be a straight first order problem. Additionally, the more blatant/classic the presentation is, the more likely it is to be high order, for obvious reasons.

Thank you for your very comprehensive posts. I’ve taken a lot of your advice throughout my step 1 study period & when I took the test last week I felt I did fine. I’m now into my step 2 CK studies & I was wondering if you could help me out on that prep.While I fully intend to follow the advice you’ve already dispensed on your post I was wondering if you had a general list of the type of questions they ask on step2 CK. I already know that

What’s the most probable diagnosis? Most appropriate next step in Mx? Most appropriate next step in diagnosis?

are the commonest forms. But as someone who’s had a lot of experience with Questions what other types of stems seem to be recurring. I know I will find all this out when I’m going through UW, but I felt its good to know at the initial stage of my prep so I can look at the prep books & try to answer these questions as I go through the content.

You’ve got the biggest three; here’s those + some variations: What’s the diagnosis What’s the most likely cause of the diagnosis What’s the pathogenesis or MOA of the condition (i.e. why hypoxia with pulmonary embolism = VQ mismatch) Additional findings with a disease (what are the physical exam, history, lab, or imaging findings) What’s the next best test What will confirm the diagnosis What’s the next step in management or best initial treatment What’s the definitive management, drug of choice, etc. What are the complications or contraindications of treatments What’s the natural history of the disease, posttreatment outcome, late effects of the disease or treatment etc.

Thank you so much for taking the time to help out all of us, I will be keeping these in mind & try to think up questions as I study! Thank you again for This blog and being thoughtful enough to extend your advice :)

Dear Ben , I have tried my very best to prepare for step 1 .At the beginning of my preparation I was motivated and hopeful for myself and lived in the fairy tale world that hard work can beat any obstacle .But every time I take an NBME it breaks my ego .I started at 217 in NBME 11 and my last NBME was 237 ( I did go upto 245 in one but I did it on self pace , probably not a good idea in hind sight ) .My goal is 250 .I am an old graduate and an IMG / I have many negatives in my resume to begin with .I want my score to help me save myself from a lot of explanations that I might have to give later on to prove my worth on the time gap anyways .My exam period ends in 4 weeks .All I have to do has to be done NOW .I am left with one NBME to check myself , the last and latest one.I took the Fred exam at the prometric recently and scored 83 % although in the same exam many people easily surpass 90% .I am so mad and sad at not being able to figure out where my deficiency is .Perhaps there are many.In my traditional school system I was not trained to be a critical thinker so through questions and UW I somewhat tried to improve that .I am a slow thinker too .I was not taught short cuts to questions that sometimes are great time savers but I tried to pick up the trends from UW as much as I could based on geography , ethnicity , gender .In one of the NBMEs they asked the most “immediate” treatment of cholinergic poisoning ; I picked up pralidoxime feeling happy that extra knowledge is helping me .Pralidoxime within 6 hrs helps inhibit enzyme aging .The answer was atropine !! and then I read forums where students were taught that no matter what a person in that condition first needs to be treated with atropine to reverse the life threatening effects .Me and my “bookish” knowledge didnt work .I cannot overcome that deficiency on my own .Numbers and calculations make me nervous when attempting a block in timed mode .Genetic questions look like riddles to me .In the real exam I might( wrongly) think they are experimental questions Cannot recognize murmurs .Electrolyte panels consume my time . I am so negative today that I have no shame in disclosing myself as a USMLE step 1 dyslexic .I was thinking of doing UW in 7 block pattern just like the real exam a couple of times OR buying Kaplan Q bank for a month but I do not want to be bogged down by low yield stuff ( which many people say Kaplan Q bank is ) now that I am so near to my deadline .At the same time I want to improve my speed and recognition of question patterns , pick up clues , improve genetics , biostatistics and acid base questions .237 to 250 thirteen measly points if only someone could steer my mind in the correct direction . 250 is MY magical number perhaps .230-250 is the first standard deviation so I want to be atleast that since I put in so many hours , effort and made significant compromises on my family time , took NBMEs , analyzed myself , moved forward with positivity SO FAR .I have study partners whom I have observed have very superficial thinking style and even they got a 82 % on the Fred ( though NBME is low ; a good 15 point low ) and I get consulted by them if they find some facts or questions hard.I think they are all better than me if they can score close to me with that thought pattern .What good is my knowledge if it doesnt translate to a rich score .

So my question is : how can I improve my score without burning myself out within the next few weeks ?

You need to start by not beating yourself up. Your specific goal of 250 is awesome and I hope you get it, but you need to know that goals are only helpful as a means of motivation. Not something to tie your entire self-worth into. That’s why you’re getting demoralized, and it’s not serving you well. A friend’s performance, peoples’ posts on SDN—absolutely none of that matters.

I would just focus exclusively on questions. If you’ve exhausted UW, then get a different qbank. USMLERx has less random stuff than Kaplan. If you haven’t memorized UW then do it again. When you get questions wrong, flag them and do them again. There are lots of reasons to get questions wrong and you need to approach the explanations as a chance to learn, not a chance to be disappointed.

I want to repeat that. The reason UW and qbanks are good tools is twofold. 1) Your knowledge is only helpful if it helps you answer a question. The best way to see how to apply it to a question is with a question. 2) The explanation teaches you both the facts and the context/test-taking/pearls/trends/etc.

A lot of people shortchange themselves on #2. They get upset when they get a question wrong and don’t use it as a learning opportunity. You should almost want to get questions wrong, because then it means you have an opportunity to improve, a potential blindspot to weed out. The other thing people do is use that negative emotional valence to overread the explanation. They take an exception and turn into a new rule. They generalize too much and try to apply something specific on one question to another question where it doesn’t apply (“but last time I guessed X and it was Y; this time it’s X, wtf!”). All of this comes from stress and self-doubt.

If you don’t have much trouble with time management, I’d continue using tutor mode for the next 3 weeks. Remember, this is about learning. Stop paying attention to how you’re doing. Whether you do bad or good or your score changes doesn’t matter. This is how you’re going to study and you’re going to embrace it. Use books to supplement as needed when an explanation isn’t enough or you hit something that requires re-memorizing a table (cytokines, glyocogen storage diseases, things of that nature). You can switch to timed blocks to simulate the exam the last week. Get into a groove. Find the confidence to go with your gut, not agonize, not get stressed by a long question stem, etc. If one particular thing seems like you’ll never learn it, then don’t. Your score doesn’t hinge on a single topic (e.g. Screw murmurs. You can get by sometimes based on the history. There aren’t that many audio murmur questions, so just don’t worry about it).

The way to not burn out is to switch your attitude from fear to excitement. You’re doing this so you can learn, and, in a few weeks, you’ll be done. That is astoundingly exciting. It’s a huge milestone.

Cannot thank you enough .I do see the pearls in your advice .I will be reading your message multiple times to apply it to the best in the last stretch of my exam . Since yesterday I have gone through your other articles even the one about how to study . I will update you .

Really found this link helpful. I’m taking step June 21st and I was trying to make a game plan for them based on what I’ve been doing so far and was wondering if you could give me some input:

1. I have about 30% uworld left. I feel like I’ve been learning a lot from it. I have about a 70% average. Based on my analysis it seems like I am getting a lot of pharm/ anatomy incorrect. I’ve been throughly reading answers trying to learn as much as possible but not annotating. I worry that I’m missing all the details and basically I get all the big stuff but I’m worried about the tiny facts that I feel like I really need to know to get a top score I haven’t been noting down or reviewing .

2. I’ve gone through most of first aid one or multiple times and for some sections I know almost every word, others I don”t.

3. been through a fair chunk of pathoma/ done some rx questions to.

Question is, how do I move forward? I have spring break in about a week and I was trying to figure out what to do. Should I finish up uworld and try to get through it again by dedicated which starts in may for me? Should I do a run through first aid more frequently and focus more on details? DO only pharmacology and make all my flashcards and try to pound that out/ keep reviewing it till dedicated? Do another q bank ( not sure which one would be good?). In terms of my personal assessment I think I have learned a ton from doing questions but what I find is that I haven’t been taking note of simple facts/ extra knowledge that will probably be necessary for getting an exceptional score. I’m wondering if my time therefore is better spent and sitting down and trying to just memorize the details in first aid or something. My goal is to get in the 250’s and I’ve generally been an honors/A student ( but got a high c in anatomy). I recognize I have limited time and I’m trying to figure out how to proceed given m strengths/weaknesses and what has worked well for me. I totally agree a huge part of it is about gaming the test and I do think uworld has taught me to get better at that and I learn incredibly well from doing questions. That said, there are still questions where I know the material but I’m getting answers wrong due to that unknown factor. How do I fix this issue/the minor detail content issue?

You have a ton of time left, and 70% on UW puts you in really excellent shape. I’d finish it up and reset it when time for dedicated review. You could also go through pharm/anatomy a second time before the reset as well if you had more time. Personally, I’d recommend using your spring break to relax or do something interesting.

Given your high percentage, you should be on track for 250’s with just hammering UW to be honest. I think you can pick up more details and hone skills via questions. That said, there’s something to be said for intermittently reviewing a section of a book to re-hit (memorize) some details all at once (things like biochem, drug side effects, common anatomic injuries, etc). You may want to trigger such focused detail-review when you get a question wrong on UW. There’s nothing wrong with using UW to guide your further/supplemental review. If you’re already hitting that high on UW, reading cover to cover is probably not worth your time.

Great, thanks. Will try that. I actually did two blocks of 40 today for the new 2016 sample usmle questions that have come out. I got 19 wrong out of 80. Is there a way to figure out what that would approximate to? Also, I’m finding that these questions are much more gimme/straightforward questions than uworld. More often than not, I got something wrong simply because I did not know it. I would look it up and find it in first aid somewhere for the most party. For instance, pulmonary hypoplasia and oligohydraminos occur in potter syndrome or what drains the dorsolateral side of the foot.

I’m feeling a bit frustrated because at this point I feel like its about just retaining random facts and I can’t be sure about what I don’t know. Or sometimes it’s maybe more of a big fact I should know (such as what does PTH do to phosphorus) but I didn’t observe many ‘critical thinking’ or ‘application’ errors besides a few. For the two blocks I did, it was units we’d already covered in school so it doesn’t seem to be a ‘new material’ issue. More like little holes or random knowledge gaps.

How would you suggest going about addressing this? I know you said in your previous post to keep hammering uworld but do you have any other ideas based on how I’m feeling about the usmle sample questions?

I guess it feels like to be a really top scorer you have to just know a lot of random facts and I don’t know which ones to know and it’s a losing battle. I think world has overall helped be get better at questions, pattern recognition so I’m really quick at some things and know where a question’s going/ what they’re trying to test. But it feels like it’s not possible for me to do super well because there’s just lots of tiny information i won’t know. I feel like i needed to start memorizing those little things in first aid much sooner and it’s too late for that now.

Most people memorize microdetails during dedicated review; they’re hard to retain, and they’re usually easier to add to your knowledge base when your foundation is rock solid. It’s not too late by any stretch. A lot of these details are included in qbank question explanations, which is why it’s important to read them carefully even on questions you get correct as you go through. Certain things (biochem, renal physio, endocrine effects, branchial cleft nonsense, etc) definitely earn repeated looks at First Aid to see them laid out in one place.

I do pretty strongly believe that it’s more about thoughtful time spent than which resources you use (so long as you’re also doing a lot of questions, which you are). There’s no other book you need to perform at a high level (i.e. if you truly had every fact in UW memorized, you’d absolutely destroy the test).

As for the percentage score on the sample questions…who knows. Several years ago a bunch of people compared their free 150 and step scores, but that was a long time ago and probably not meaningful anymore. I’d arbitrarily guess around 220, but 80 questions is too few to make anything meaningful out of.

I am getting ready to take Step 1 and I have gone through UW about 2 times. I have improved so much from the first time I went through it, but I think I need a new question bank. Could you suggest a question bank other than UW please? What do you think about the becker question bank? Should I still use UW question bank?

After I finished the UW the second time I went and took a UW practice test and it did not reflect how well I had done in the question bank. I was so disappointed and felt like all my UW work and FA reading was for nothing. When I went through the practice test I saw that a few of the ones I missed was not because I didn’t know the info, it was because I couldn’t remember the little details or changed my answer. I thought I was on the right track in my step study until I took that practice test. I have to take my step 1 in a little over a month. Do you have any advice?

I’m not familiar enough with the contemporary versions of the alternative qbanks to give a specific recommendation. Generally, people would recommend either Kaplan or USMLERx, which Kaplan being felt to be microdetailed and thus very difficult and Rx to test the same material as First Aid (which could be good or bad). Either one of those may be more in line with your goals.

I’ve heard nothing very positive about Becker and see no reason to choose it at this point. You might check to see if your school has a institutional subscription to BoardVitals. A lot of schools do and it’s a reasonable choice especially if free. I would still make sure to redo the questions you had to guess on or got wrong on UW during your second pass through. It’s not about recognizing the right answer, it’s about knowing that material and the way it can be tested. So the harder questions deserve more of your time.

I address the issue of changing answers and a few other things in this post.

Thanks for pointing out what rules to adopt when choosing between a test and management. And also the rationale required in order to pick the right answer for the exam.

Could you kindly refer me to the source? sources? that lists of how to tackle questions this way?, i.e. that would explain the rules you have mentioned…………….

“When patients are stable, the “next best step/most appropriate test” is that which is most likely to make the diagnosis (always know the test of choice, especially for imaging studies) or rule out a less-likely but potentially life-threatening diagnosis. If the diagnosis is already made, treat the problem (there may be two treatments, but one is more important). Other tests may be reasonable and performed concurrently in real life, but there is typically one test that is geared towards the most likely diagnosis based on presentation.”

“So—

Stabilize if necessary — ABCs, even for non-trauma patients Diagnose if necessary — Test of choice to make the diagnosis or the test that will rule out a potentially life-threatening cause Treat — If there are multiple appropriate options, which one is the most crucial?”

Many thanks for your kind reply. Is there a better resource than these two — Review book-based, question bank-based sources?

Something that is more official? a standard textbook? standard resource? that the question writers might refer? school teachers might point student to? that dissects and points out to the actual rules to adopted when answering questions pls?

While the material would likely be in any subject textbook, I can’t think of any that tend to frame it in that manner (caveat being that I certainly haven’t read most/all of the textbooks on the market).

Question writers often cite articles and not textbooks. When they cite books, they do tend to cite the major textbooks. That being said, the nuances they’re testing may be more implicit in the resource. With regard to the next step type questions, it’s more an application of general clinical principles (like I mentioned above) to a disease or condition that leads to these choices, not each thing being explicitly described as such in a book.

Not since 2012 (sorry!). The site I’ve always been happy to do for fun, but I don’t think medical students could/should pay enough for tutoring services to generate time in my schedule (especially with the little one around).

Ben, can you comment on what is known and unknown about the way step 1 is scored? We know a little about the history of the score reporting. It was originally pass/fail with a 2 digit score for the test taker to use for his own purposes. Then the 3-digit score came out. Now Residency programs use the 3 digit score as a critical metric for screening applicants out of lucrative fields. So my question is, are people putting too much value on the Step score? And what data is there to correlate overall knowledgability/intelligence with step scores?

From what I know, the three digit score is just a more granular two digit score with a higher roof. The two digit score capped too easily at 99 to make discrimination between highly qualified applicants. It’s a normalized test with big standard deviation. So in 2015, the average score was 229 (20), which means that the vast majority of test takers a performing in the 209-249 range. Those 270+ scores are thus very rare.

The standard error of measurement (SEM) is about +/- 5 for Step 1, which means that 2/3 of an examinee’s observed scores should fall within the 10 point range surrounding their score. This also means that 1/3(!) of an examinee’s test attempts would have a score outside that 10 point range. So having a bad (or good) day is pretty common. You may find this worth reading.

As to your second question, I don’t know about general intelligence vs Step scores correlation, I imagine it’s moderate, probably lower than the MCAT and much lower than the SAT. It’s much more dependent on memorization than reasoning. The evidence that Step scores correlate with residency performance is pretty bad, though anecdotally they apparently correlate with board passage rates, which is important in some subspecialties with difficult boards. But yes, of course, people are putting too much emphasis on Step 1. It’s a multiple choice test, a terrible proxy for anything having to do with taking care of people. That being said, the same applies to the SAT and MCAT. In fact, the MCAT is terrible for what we use it for.

When you need to sort through a big stack of people, it’s helpful to have something “objective” to make comparisons between. Particularly with highly variable grading schemes and pass/fail curricula etc, Step 1 is allowing programs to compare “academic” performance across all schools. What does a high pass at the University of Whatever require vs Honors at Whatever State vs Pass at Harvard vs Pass at Hopkins? Who knows. That’s why it’s helpful, and for that purpose, it does the job. Many programs simply use a threshold approach when considering applicants and do not directly compare scores past that point (i.e. 245 isn’t magically better than a 240), and that’s probably the healthiest way to do so. Ironically, Step 2 CK is the in-school test that at least has some reflection of clinically relevant knowledge, and it’s significantly less important. Step 3 is mostly superfluous, just like Step 2 CS.

Hi Ben, I’ve read several of your posts for the first time and I’ve found them very helpful. Thanks! I’m a non-US IMG getting ready for Step 2 CK. Since our teaching plan is different from the American one, I chose to do first Step 2 CK since all clinical rotations make it to be fresher in my mind. I’m a bit lost about % of performance in UW and NMBE correlated with the final Step’s score. I was wondering, do you know anything about it that could orient me a bit? For example, in order to get >240 (I’ve read for surgeries this is the minimum needed), which % would be correlated in the UW/NMBE? Thanks so much!

There are random forums posts that show up if you try to look this up, but Step 2 CK doesn’t seem to garner nearly as much correlation discussion as Step 1. I don’t have any good rules these days; it’s been a fair amount of time since I did any research into it.

Hi Ben, Not sure if you’re still responding to these but I found this extremely helpful especially the part where you said ” “Female athlete” is a code word for “eating disorder” (the answer is E). If the question mentioned a boxer, wrestler, or other sport with weigh-ins, ditto. Board questions reflect an extremely judgmental worldview with heavy-handed generalizations about race, sex, and a wide variety of stereotypes. African-American females in their 30-40s have sarcoidosis. If a woman takes oral contraceptive pills, the question is nearly always implying that she doesn’t use barrier protection and has contracted an STD. People who have recently immigrated from another country with cough have tuberculosis. If it’s a child who has recently immigrated, then they have a vaccine-preventable illness.”

Could you please expand on this? Maybe do a whole article with good generalizations like these? I know there are buzzword books and a whole section in FA but none of them broke it down like you did, and I mean NONE. In the week that I read this I have gotten several questions right just by using this standard of thinking. Thank you so so much in advance!!

If you had asked me several years ago I’d probably have a bigger laundry list of those. I haven’t done any Step posts in a while, but there are definitely some classic setups scattered throughout all qbanks. If you can catch the take home point you’ll know it forever.

Quick question: can the absence of a finding reported on a diagnostic exam in a vignette be taken to mean that the finding was normal at the time? A lot of UWorld questions seem to rely on this to answer questions but then you get the occasional one where the absence of a finding doesn’t mean it wouldn’t have been positive if it was reported.

I’m not sure there’s a consistent answer for that. It’s probably true a lot but should probably be just a datapoint in choosing the single best answer. Like in the real world, I imagine it would depend on both the pathology and the test. Nothing is 100% sensitive or specific.

The service you’re doing to the future physicians is incredible.. How did you develop this habit? Do you love blogging or you were inspired by someone? I am definitely inspired by your blog one day I wanna be like you .. oh, did I mention ?! I love the way you keep things simple, crisp & easy to understand.

Thank you for your kind words. I did blog for a few years in college way back when such things were sorta uncommon (I’m actually not sure why, this was back in 2006–maybe Andrew Sullivan was an inspiration?), so I knew how to do it when I started writing here in 2009. It was, of all things, part of a New Year’s Resolution to write more. Medical school was boring!